Be smart when navigating the insurance and Medicare markets

Diane M. BartonSeptember 20, 2017

Chiropractors are trying to bring more money into their practices by figuring out how to legally and ethically squeeze every penny out of Medicare (and other insurers), while still following strict regulations.

The Medicare and CHIP Reauthorization Act (MACRA) is touted as the biggest thing in Medicare since the birth of Medicare itself because it promises to put more money in the pockets of chiropractic providers treating Medicare patients. If this payment system is successful, insurance companies such as Blue Cross Blue Shield, United Healthcare, and Aetna are considering emulating the program.

The reward system

The MACRA system will have two payment paths. One is the Advanced Payment Model (APM), which is designed for larger medical groups, hospitals, and health systems. The second, the Merit-Based Incentive Payment System (MIPS), is designed for smaller or solo practitioners.

Under MIPS at this time, a provider with 100 or more unique Medicare patients who bills Medicare for at least $30,000 in claims during a one-year period will automatically be assigned to the MIPS payment system.

Doctors who do not meet the two MIPS requirements can choose to enter the MIPS payment system as well. Though MIPS promises to put more money into the coffers of a practice, one should not think that doing things the old way will suffice to reap the benefits.

So what does the MIPS payment system entail and what are the rewards? The biggest change is that MIPS will be based on the quality rather than the volume of care.

By the numbers

As of January 1, 2017, doctors are being evaluated for their quality of care, resource use, clinic practice improvement activities, and meaningful use of electronic health records. Beginning January 1, 2019, Medicare providers can receive reimbursement payment increases of 0.5 percent with possible total increases going up to 9 percent by 2022. Providers can earn bonuses, and there is a possibility that reimbursement payments could be three times more for a total of 27 percent.

On the other hand, this program is budget neutral, which means some providers lower on the spectrum will lose money if they fail to comply with MIPS requirements. After each doctor is evaluated, they will receive a rating score that will be available to the public. If you have a higher-than-average score, there is a greater chance of drawing new patients to your office. Quality of care will be 60 percent of the rating score.

Doctors need to work on correcting several concerns: quality of care, patient documentation, and coding and billing. The claim form is the first communication the provider has with Medicare and other insurance companies. Billing errors or billing for maintenance will count against a provider’s rating score, resulting in a lower reimbursement rate, causing doctors to lose money.

And then those audits

Having a lower reimbursement rate is not the only way doctors can lose money. CMS has contracted Strategic Health Solutions (as well as other companies), to conduct review audits of doctors who have ranked among the top 10 percent of Medicare providers in each state under Project Y4P0434, which began January 1, 2017. Under this project, doctors are requested to provide up to 40 charts, and they may be asked for additional charts in the future.

These companies will forward audit results to CMS, who will decide if claim adjustments—or recoupment of payments—should be made to Medicare. Rumor has it that once the top 10 percent of providers have been audited, the next audits will focus on those providers in the next 10 percent, followed by audits from commercial third-party payers.

An effective compliance program, designated compliance officer, and OIG/Medicare manual are requirements for participating in federal healthcare programs. If inspectors find proper compliance programs in a practice under audit, that could mean the difference between mistakes being viewed as errors or as evidence of fraud or abuse.

Compliance programs can also prevent possible fines, penalties, or expulsion from participation in federal healthcare programs. Another benefit to compliance programs is that they can help prevent anti-kick- back and Stark law violations as well, helping you stay out of trouble. Additionally, these can make your practice more productive, reduce errors, increase revenue, and stream- line your office management.

A HIPAA compliance program is not the same as a Medicare/OIG compliance program (though the two programs should mesh together).

Each program requires its own manual with office-specific policies and procedures. Whereas HIPAA focuses on protecting and securing patients’ protected healthcare information (PHI), the OIG focuses on fraud, abuse, and waste of money or services as well as enforcing the False Claims Act.

The Medicare/OIG compliance program is built around the seven elements of a compliance program, which is derived from federal sentencing guidelines. Purchasing a manual in the hope it will be an effective and proper compliance program for your practice will only lead into murkiness, and pretending to have a compliance program can lead to serious consequences. The seven elements of a compliance program are as follows:

Having written policies and procedures specific to the

Having a designated compliance

Having accessible lines of communication so your staff can reach the officer in the event there is a compliance concern.

Conducting comprehensive staff and employee training at least once a

Performing internal monitoring and auditing that is completed by an

Enforcing standards based on published regulations and

Responding promptly to detected issues and taking corrective

Two additional elements are necessary for an effective Medicare/OIG compliance program. The first is to check all staff, employees, vendors, or other service people who may be paid out of funds received from federally funded healthcare programs.

These checks should be done monthly through the OIG’s exclusion list on their website, the FBI website, state registries, local courthouses, and search engines such as Google. If anyone engaged with your practice is found to be on these lists, they are to be exempted from working on federally funded programs.

Because proper documentation of patient charts, coding, and billing is so important to earning and keeping money—as well as eliminating fraud and abuse—CMS requires annual chart audits performed by independent certified entities—to ensure the audit is performed from an unbiased perspective.

Given the potential money your practice can make under MIPS, and the many ways you can lose it, get your practice in order to protect yourself.

Diane M. Barton, DC, MCS-P, CIC, is a graduate of Palmer College. She has been in practice for 28 years in the Chicago area.

James Minx, MCS-P, CIC, graduated from Western Illinois University with a degree in law enforcement. He retired as a sergeant from the Illinois State Police in 2010. Barton and Minx have presented various sessions on compliance matters and own Medical Compliance Specialists. They can be contacted through medicalcompliancespecialists.com.